Giant androgen-producing adrenocortical carcinoma with atrial flutter: A case report and review of the literature

Table 1 Pre- and post-operative hormone levels and echocardiography

	Preoperative	Postoperative			Normal range
		1-d	3-mo	6-mo
Hormone
Total testosterone (nmol/L)	8.42-10.11	1.77			0.22-2.9
DHEAS (μg/dL)	864.2-1492	31		< 0.1	9.4-246.0
Cortisol (μg/dL): a.m.	-	11.8	31.3	3.2	3.7-19.4
Cortisol (μg/dL): p.m.	24.1	-	-	-	2.9-17.3
Androstenedione (ng/mL)	> 10				< 2.11
17-OH progesterone (ng/mL)	> 251	1.85			0.2-0.9
Urinary metanephrines (μg/24 h)	49.8				25-312
FT4 (ng/dL)	1.13	1.55			0.89-1.76
FT3 (pg/mL)	2.64				2.2-5
TSH (μUI/mL)	3.46				0.4-4
Peptide C	8.53				0.9-7.1
Glucagon (ng/L)	207				< 209
FSH (mIU/mL)	< 10				21.7-153
LH (mIU/mL)	< 10				11.3-39.8
PTH (pg/mL)	32.46				15-63
Echocardiography
Left atrium dimension (cm)	45			44	3.0-4.0
Left atrium volume/index (mL/m2)	57/33			56/33	22 ± 6
Left ventricle dimension (cm)	60			45	4.2-5.9
Estimated ejection fraction (%)	28			57	50-80
Estimated pulmonary artery pressure (mmHg)	46			20	9-18

DHEAS: Dehydroepiandrosterone sulfate; FSH: Follicle-stimulating hormone; FT3: Triiodothyronine; FT4: Thyroxine; TSH: Thyrotropin; LH: Luteinizing hormone; PTH: Parathyroid hormone.

Table 2 Characteristics and evolution of giant adrenocortical carcinoma from case reports in the literature

Ref.	Time until diagnosis	Age (yr)	Sex	Type of tumor	Dimensions	Weight (g)	Metastasis (yes/no)	Ki67 proliferation index	Disease-free interval	Treatment
Functional
Kunieda et al[39], 2000	4 mo: Weight loss and abdominal discomfort	52	M	Functional cortisol	29 × 19 cm × 10 cm	4700	Yes (liver and right kidney)	NA	5 yr	Surgery + mitotane 4 g/d, 3 mo
Uruc et al[13], 2015	Abdominal pain, flushing	48	F	Functional sex-hormone secreting	23 cm × 18 cm × 16 cm	1300	Yes (capsular invasion)	> 10%	NA	Surgery + mitotane
Bagchi et al[14], 2015	10 mo: Altered menstrual symptoms; the last 5 mo: Headache, palpitation, anxiety, abdominal pain	35	F	Functional cushingoid features, pheochromocytoma	21 cm × 12 cm × 8 cm	NA	Yes (microvascular invasion lymphovascular)	NA	1 yr	Surgery
Nonfunctional
Zhou et al[40], 2019	9 mo: No clinical symptoms	77	M	Nonfunctional	30 cm × 15 cm × 8 cm	NA	Yes (local right- abdominal musculature)	> 80%	9 mo	Surgery
Chatzoulis et al[1], 2018	Few months: Flatulence and epigastric discomfort	39	F	Nonfunctional	23.7 cm × 16.5 cm × 11.5 cm	NA	No	NA	1.5 yr	Surgery
Bacalbasa et al[41], 2015	3 yr; last months: Abdominal diffuse pain, subocclusion, lower limb edema	65	M	Nonfunctional	35 cm × 30 cm × 25 cm	18500	Yes	NA	1 yr	Surgery
Stievano Carlos et al[42], 2014	6 mo: Abdominal pain; last 2 mo: Weight loss	49	F	Nonfunctional	21 cm	2106	Yes (hepatic metastases)	NA	22 mo	surgery
Straka et al[30], 2014	14 d of respiratory distress	40	M	Nonfunctional	26 cm × 16 cm × 13 cm	2372	Yes (lymph nodes with invasion to retro-peritoneal structures)	NA	36 mo	Surgery
Singh and Gupta[43], 2011	Last 2.5 mo: Vague abdominal pain in the left upper quadrant	47	M	Nonfunctional	22 cm × 18 cm × 15 cm	2800	Yes (microscopic lymphovascular invasion limited to the capsule and small vessels)	NA	5 yr	Surgery

M: Male; F: Female; NA: Not available.